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GH 87 y/o Male, Assessment:, Diagnostic Tests, Medications, Lorazepam 0.5…
GH 87 y/o Male
Primary Diagnosis: COPD
Pathophysiology
Chronic and recurrent obstruction of airflow in the pulmonary airways (Norris, 2020)
Risk Factors (Norris, 2020)
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Nursing Problems
Problem 3
Activity Intolerance
Client-Focused Outcomes
Client will ambulate QID with demonstrating increased tolerance to activity during stay (Ackley et al., 2019)
Interventions
Nurse will refer patient to physical therapy to help build strength and activity levels (Ackley et al., 2019)
Nurse will keep an eye on symptoms of intolerance during activity (Ackley et al., 2019)
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Problem 2
Imbalanced Nutrition
Client-Focused Outcomes
Client will consume adequate nourishment during stay (Ackley et al., 2019)
Interventions
Nurse will monitor food intake and encourage the client to eat small frequent meals (Ackley et al., 2019)
Nurse will encourage ambulation and physical activity to improve metabolism (Ackley et al., 2019)
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Problem 4
Risk for Infection
Client-Focused Outcomes
Client will remain free from infection during stay (Ackley et al., 2019)
Interventions
Nurse will observe and report any signs of infection (Ackley et al., 2019)
Nurse will encourage fluid intake (Ackley et al., 2019)
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Secondary Diagnosis: Hypoxemic Respiratory Failure, chronic
Pathophysiology
Condition in which the lungs fail to oxygenate blood adequately or prevent undue retention of carbon dioxide (Norris, 2020)
Risk Factors (Norris, 2020)
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Assessment:
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Respiratory: LS are clear, Client is on 2 L of O2, claims to be a former smoker
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Cardiac: S1, S2 heart sounds present. Client states he has high BP
GI:Client has bowel movement today, reports no problem with bowels
Musculoskeletal: Client uses a walker to ambulate around the hallway and outside. He needs O2 when walking around which limits his motivation to walk.
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Lorazepam 0.5 mg PO BID @ 08,20
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